MARYLAND MEDICAL ASSISTANCE PROGRAM Pharmacy Transmittal No Maryland Pharmacy Assistance Program Transmittal No. 39 February 22, 1999

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1 1 PT17-99 MARYLAND MEDICAL ASSISTANCE PROGRAM Pharmacy Transmittal No. 160 Maryland Pharmacy Assistance Program Transmittal No. 39 February 22, 1999 TO: FROM: NOTE: RE: Physicians Pharmacists Martin P. Wasserman, M.D., J.D. Secretary Please ensure that appropriate staff members in your organization are informed of the contents of this transmittal. New Medicaid Pharmacy Point-of-Sale (POS) System On January 4, 1999 a new Pharmacy Point-of-Sale (POS) contract became effective with First Health Services Corporation. The new contract provides for many enhancements to the current system such as automatic preauthorization, improved third party liability collection procedures, Medicare cost avoidance, improved prospective drug utilization review procedures and a web page. Certain prescriptions such as anti-ulcer medications and some drugs under the Maryland Pharmacy Assistance Program currently require the physician to make notations for coverage. With the new system these requirements will be expanded and there will be better enforcement. Below is a listing of the new features in this transmittal. Automatic Preauthorization p. 2 H2 Blockers and Proton Pump Inhibitors p. 2 Third Party Liability p. 2 Medicare Cost Avoidance p. 3 Verification of Diagnosis for Pharmacy Assistance Coverage p. 3 Coordinated Prospective Drug Utilization Review (Pro-DUR) p. 4 DEA Number as Prescriber Identifier p. 4 Pro-DUR Denials for Drug-drug Interactions and Therapeutic Duplication p. 4 Extemporaneously Compounded Prescriptions p. 4 Web Page p. 5 Kidney Disease Program p. 5 List of Drugs Requiring Diagnosis under Maryland Pharmacy Assistance p. 6-7

2 2 Automatic Preauthorization Effective January 4, 1999, the new system will automatically override the early refill edit on any prescription for a non-controlled substance having an increase in dose and a new prescription number. H2 blockers & Proton Pump Inhibitors Effective 60 days from the date of this transmittal, proton pump inhibitors are being added to the list of anti-ulcer medications requiring the diagnosis be written on the prescription by the prescriber for use beyond the acute treatment period for active ulcer. The prescriber must write the diagnosis on the prescription for H2 blockers and proton pump inhibitors for use beyond 68 days of acute dose therapy. Currently acute dose anti-ulcer H2 blocker drugs are denied based on the refill number. The new system has the capability of looking back at the prescription history to determine the length of time at the acute dose level. When effective, prescriptions at the acute dose for H2 blocker and proton pump inhibitor medications will deny when used more than 68 days in any 100 day period. If the pharmacist receives a denial for one of these prescriptions he should call the First Health help desk. The help desk will ask for verification that the correct diagnosis is on the prescription and preauthorize the prescription to allow adjudication on-line. If the pharmacist cannot document the proper diagnosis, the pharmacist will be told to call the State at Below is a list of the acute dosage levels and the list of acceptable diagnoses. Drug Acute dose Ranitidine (Zantac) 300mg/day or greater Cimetidine (Tagamet) 800mg/day or greater Nizatidine (Axid) 300mg/day or greater Famotidine (Pepcid) 40mg/day or greater Omeprazole (Prilosec)40mg/day or greater Lansoprazole (Prevacid) 30mg/day or greater Acceptable Diagnoses Hypersecretory condition Zollinger-Ellison Syndrome (ZE) Gastroesophageal reflux disease (GERD) Esophagitis Erosive Esophagitis Barrett s Disease Barrett s Esophagitis Unhealed Ulcer Multiple endocrine adenomas Systemic mastocytosis Third Party Liability (TPL) Effective 60 days from the date of this transmittal, prescription claims for recipients will be denied if Medicaid records indicate that the recipient has other

3 3 prescription coverage. Medicaid is the payer of last resort. If a recipient has prescription insurance other than Medicaid that pays directly to the pharmacy for medications, the pharmacy must bill that carrier before billing Medicaid. If the other carrier does not pay the full amount, the Program will pay the difference between the amount paid by the insurance and the amount that Medicaid would have paid had it been the primary payer. The pharmacist should submit the claim to Medicaid with a 2" in the TPL indicator field and enter the amount that the other carrier paid in the TPL amount field. If the pharmacist determines that the recipient does not have other insurance, the claim should be resubmitted with TPL indicator of 1". If it is determined that this particular drug is not covered by the insurance, the pharmacist should resubmit the claim to Medicaid with TPL indicator 3". If the prescription is covered by the other carrier but the pharmacy does not participate in the insurance network, the pharmacist should resubmit the claim with TPL indicator 4. Note: If a carrier requires the enrollee to pay for medications and then reimburses the enrollee directly or a carrier is precluded by Federal regulations to cover prescriptions, the Program will pay the pharmacy and then seek recovery from the other carrier. Medicare Cost Avoidance Effective January 4, 1999, claims for the immunosuppressant drugs Sandimmune, Cellcept, Prograf, Imuran and Neoral will deny for recipients having Medicare Part B coverage. If the date of service is within three years of the hospital discharge date for the transplant, Medicare should be billed. If dispensed more than three years from the transplant discharge date, the help desk can be called for a lifetime override. Medicare Part B also pays for some oral anti-cancer drugs. Claims for oral anti-cancer drugs for recipients with Medicare part B will continue to deny on-line and should be billed to Medicare. If used for arthritis or a medically accepted use other than for the treatment of cancer, the help desk will preauthorize these drugs to pay on-line when resubmitted. Verification of Diagnosis for Pharmacy Assistance Coverage Effective 60 days from the date of this transmittal, the new system will require the pharmacist to verify the proper diagnosis where required for coverage under the Maryland Pharmacy Assistance Program (MPAP). Many drugs under the Pharmacy Assistance Program are covered only when used to treat a specific condition. Claims for drugs requiring the diagnosis will deny and the pharmacist must enter an 8" in the PA/MC field as verification that the recipient has the diagnosis required for coverage. If the diagnosis is not written on the prescription by the prescriber, the pharmacist can determine the diagnosis by either calling the prescriber or talking with the recipient and documenting on the prescription that the diagnosis is appropriate for MPAP coverage. Any notation made must be dated and initialed by the pharmacist. The pharmacist can submit a PA/MC code of 8" with the original submission to pre-empt a denial if the diagnosis has been verified and documented. The Program will conduct retrospective reviews of these claims and may recover the cost of any prescription not having the proper documentation. Please refer to the attached sheets with the list of required diagnoses. Coordinated Prospective Drug Utilization Review (Pro-DUR)

4 4 The Program will begin implementation of the new Coordinated Pro-DUR System. When operating, the system will automatically link the drug history for the somatic drugs paid by the MCO with the drug history for the Specialty Mental Health and AIDS carveout drugs paid by the State to allow a comprehensive prospective drug utilization review. Implementation will be in stages with one MCO being done at a time. By July, 1999, all MCOs should be participating. DEA Number as Prescriber Identifier The Coordinated Pro-DUR system requires standardization of data elements. To accomplish this the Medicaid Program is planning to use DEA number as prescriber identification. This is consistent with most of the other third party payers. Pro-DUR Denials for Drug-Drug (DD) Interactions and Therapeutic Duplication (TD) Effective 60 days from the date of this transmittal, the Program will deny claims for certain drug-drug and therapeutic duplication drug interactions. The pharmacist must take the appropriate action to resolve the DUR problem. If it is determined that the prescription should still be filled, the pharmacist must resubmit the claim with an intervention code and an outcome code for the claim to pay. The intervention and outcome codes to be used are listed below. Intervention codes ØØ No intervention MO Prescriber consulted PO Patient consulted RO Pharmacist consulted other source PE Patient education/instruction Outcome codes 1A Filled as is, false positive 1B Filled prescription as is 1C Filled with different dose 1D Filled with different directions 1F Filled with different quantity 1G Filled with prescriber approval Note: Use of outcome codes 1C and 1F requires a change to the dose or quantity fields. Extemporaneously Compounded Prescriptions Effective 60 days from the date of this transmittal, the blanket National Drug Code (NDC) for extemporaneously compounded prescriptions will no longer be accepted for prescriptions over $12. The NDC of the most expensive ingredient must be used along with the quantity of that ingredient and submitted with compound code 2" (or yes, depending on software). If unable to enter the quantity of the most expensive ingredient, then enter the total quantity of the prescription, which will be adjusted during manual review of the claim. The claim will pend and the compounding form must be filled out and sent in with a copy of the prescriber s order to the Medical Care Operations

5 5 Administration (MCOA), P.O. Box 2158, Baltimore, MD 21203, so that the prescription can be accurately priced. Web Page Effective January 4, 1999, First Health Services will maintain a web page for the Maryland Medicaid Pharmacy Program that will contain the Provider manual, the latest Transmittals, and other information concerning the Program. The address is Kidney Disease Program Effective January 4, 1999, prescriptions for the Kidney Disease Program can be submitted on-line via the POS system. For more information please refer to the Kidney Disease Program at Questions concerning this transmittal should be directed to the Manager for Pharmacy Services at DRUGS REQUIRING DIAGNOSIS UNDER PHARMACY ASSISTANCE Drug Required Diagnosis Non-steroidal anti-inflammatory drugs (NSAIDs) All covered products Chronic rheumatic and arthritic conditions Opiate agonists Codeine phosphate Pain relief for terminally ill patients only Fentanyl, transderm patch Hydrocodone bitartrate Hydromorphone Hcl Levorphanol tartrate Meperidine HCl Methadone Morphine sulfate Opium preps Oxycodone Oxymorphone HCl Propoxyphene Hcl, napsylate Barbiturates Phenobarbital Anticonvulsant use Benzodiazepines Clonazepam Anticonvulsant use Clorazepate Respiratory and cerebral stimulants Methylphenidate Narcolepsy and attention deficit Dextroamphetamine disorders in individuals under Pemoline 16 years of age

6 6 Benzodiazepines Alprazolam Benzodiazepines Diazepam Lorazepam Ammonia Detoxicants Lactulose Enzymes Alglucerase Miscellaneous GI drugs Cimetidine Cisapride Famotidine Nizatidine Ranitidine Miscellaneous GI drugs Omeprazole Lansoprazole Oral and parenteral adrenals Betamethasone Cortisone acetate Dexamethasone Fludrocortisone Hydrocortisone Methylprednisolone Prednisolone Prednisone Triamcinolone Androgens Oxymetholone Androgens Stanozolol Topical anti-inflammatory agents Fluocinolone Triamcinolone acetonide Betamethasone dipropionate Panic Disorders Chronic anxiety Portal system encephalopathy Gaucher disease Zollinger-Ellison Syndrome, duodenal ulcer or gastroesophageal reflux disease Erosive esophagitis or pathological hypersecretory conditions Replacement therapy in adrenal insufficiency Treatment of anemias caused by deficient red blood cell production Hereditary angioedema Treatment of psoriasis

All Indiana Medicaid Prescribers and Pharmacy Providers

P R O V I D E R B U L L E T I N BT200148 NOVEMBER 28, 2001 To: All Indiana Medicaid Prescribers and Pharmacy Providers Subject: Note: The information in this bulletin regarding prior authorization payment